Many of you may be familiar with the Joint Commission’s standard practice for inaccessible fire dampers: If the fire damper is inaccessible during the required testing period, the hospital can choose to insert the damper into the Statement of Conditions Plan for Improvement (PFI) list with a 6-year projected completion date. Then the hospital does not have to resolve the inaccessible fire damper, and they will not be cited for not performing the required testing.
Well, no other accreditation organization (AO) or state agency surveying on behalf of CMS has that luxury. CMS has been very clear to all AOs: If you observe a deficiency, then you must cite it. AOs and state agency surveyors are not permitted to not cite a deficiency if they are presented evidence that a feature of the Life Safety Code is non-compliant. And an inaccessible fire damper on a PFI list is clear evidence that it has not been tested.
So, why does Joint Commission continue to allow their hospital clients to not test inaccessible fire dampers and permit them to place them on the PFI list if CMS does not allow this practice? It is my observation that the reason is mainly due to the fact Joint Commission has been operating as an independent authority since 1965 without having to meet CMS’s rules and regulations, until just recently (2009).
For the record, I like the Joint Commission PFI list and think it is a very good deal for hospitals. It provides the hospital an incentive to get out and find their deficiencies before a survey and manage a solution to them through the PFI list. Then a TJC surveyor will not cite them for the deficiency. It’s a win-win situation. Hospitals are motivated to conduct self-examinations of their facilities and find all the LSC deficiencies they can, which results in a safer environment for their patients. I wish all AOs and state agencies had that option. However, CMS is threatening to remove the feature from Joint Commission and if they succeed, then the fear is hospitals will not be pro-active and look for their own deficiencies, and sit back and wait to see if the surveyors will find them during the triennial survey.
Even if Joint Commission allows you to manage the inaccessible fire damper through the PFI list, that’s only good for a Joint Commission survey. You still need to make the damper accessible and then test it for all the other AHJs.
So, when a fire damper cannot be tested because it is inaccessible… you have little choice but to make the fire damper accessible and then test it. There is another option though; you may request a waiver during the Plan of Correction process, provided it is a significant hardship to the hospital. Waivers are much more difficult to get approved lately through CMS but it is the only other option to you.